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Mod A Unit 3


tid three times a day
qid four times a day
adlib as desired
Tylenol APAP
hours of sleep hs
as needed PRN
bid two times a day
pain pn
immediately STAT
night noc/noct
blood pressure BP
beats per minute BPM/bpm
temperature temp
pulse P
respiration R
pain scale PS
shortness of breath SOB
ambulatory amb
complains of C/O
right eye OD
left eye OS
both eyes OU
right ear AD
left ear AS
both ears AU
drop gt
grain gr
encephal/o brain
cerebell/o cerebellum
dur/o dura mater
mening/o meninges
radicul/o, rhiz/o nerve root
dermat skin
spin/o spine
spondyl/o,vertebr/o vertebra
ia condition
graph record
osm/o sense of smell
hydr/o water
To advise means to counsel
Litigation is a lawsuit
When something is not movable, we use the term stationary
Care involves all the health needs of the pt holistic
During the interview, the medical assistant questions the patient as follows: “Describe your pain for me. This is an example of a open-ended question
An effective relationship that considers both physical and emotional needs rapport
Being a good communicator means that the medical assistant will effective in sending and receiving the message
Growth and development process involving physical, social, and emotional functions maturation
Are you an only child is an example of a closed question
The use of arm gestures, facial expressions, and turning one’s head are all examples of nonverbal communication
The tone of voice, speed of speech, and sighing on the part of the patient while speaking are all examples of verbal communication
When you are interviewing a patient, the use of closed questions is indicated when you are looking for one word
Words formed from the first letter of several words acronym
delayed pt should be treated based on their level of maturation. developmentally
A method of arranging files using straight numbers numerical
Factors that reduce the effectiveness of communication include language and culture
A type of chart format the divides each pt’s problem into subjective, objective, assessment, and plan data SOAP
In order for the medical office to submit forms for the patient to the insurance company, the patient usually needs to sign a release form
The ability to process new information and to apply it appropriately in a given setting reflects a pt’s mental function
The patient making the statement, “I feel like someone is pounding nails into my head,” would have this statement documented in the SOAP format under subjective data
The second unit in alphabetical filing is the pt’s first
The most common method of filing is alphabetical
In the alphabetical each name is broke down into units
Diagnostic tests, medications, and treatments to be started are documented in the SOAP format under plan
The medical record is owned by doctor
Information in the medical record is owned by patient
The physician’s preliminary diagnosis is documented in the SOAP format under assessment
Assessing ______________________from the receiver allows you to determine if the message was understood the way it was intended. feedback
The process of documenting events and services concerning the pt’s care charting
Words that show action in a sentence verb
Words that describe the contents, name, or subject matter on a label caption
How many feet should you stand back to respect someone’s personal space 1.5-2.5
What percentage of communication is nonverbal 90%
The process of underlining a keyword to indicate how a document should be filed coding
Created by: pdeal